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Critical care
Original research
Non-invasive ventilation versus invasive weaning in critically ill adults: a systematic review and meta-analysis
  1. Karen E A Burns1,2,3,4,5,
  2. James Stevenson6,
  3. Matthew Laird6,
  4. Neill K J Adhikari1,7,8,
  5. Yuchong Li2,5,
  6. Cong Lu2,5,
  7. Xiaolin He5,
  8. Wentao Wang9,
  9. Zhenting Liang8,
  10. Lu Chen2,5,
  11. Haibo Zhang1,2,5,10,
  12. Jan O Friedrich1,2,3,5
  1. 1 Interdepartmental Division of Critical Care Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  2. 2 Departments of Critical Care and Medicine, Unity Health Toronto – St. Michael’s Hospital, Toronto, Ontario, Canada
  3. 3 The Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  4. 4 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
  5. 5 Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
  6. 6 The School of Medicine, Royal College of Surgeons, Dublin, Ireland
  7. 7 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  8. 8 Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
  9. 9 The Department of Critical Care Medicine, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
  10. 10 Department of Anesthesia and Physiology, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Karen E A Burns, Critical Care, Unity Health Toronto, Toronto, Canada; karen.burns{at}unityhealth.to

Abstract

Background Extubation to non-invasive ventilation (NIV) has been investigated as a strategy to wean critically ill adults from invasive ventilation and reduce ventilator-related complications.

Methods We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, proceedings of four conferences and bibliographies (to June 2020) for randomised and quasi-randomised trials that compared extubation with immediate application of NIV to continued invasive weaning in intubated adults and reported mortality (primary outcome) or other outcomes. Two reviewers independently screened citations, assessed trial quality and abstracted data.

Results We identified 28 trials, of moderate-to-good quality, involving 2066 patients, 44.6% with chronic obstructive pulmonary disease (COPD). Non-invasive weaning significantly reduced mortality (risk ratio (RR) 0.57, 95% CI 0.44 to 0.74; high quality), weaning failures (RR 0.59, 95% CI 0.43 to 0.81; high quality), pneumonia (RR 0.30, 95% CI 0.22 to 0.41; high quality), intensive care unit (ICU) (mean difference (MD) −4.62 days, 95% CI −5.91 to −3.34) and hospital stay (MD −6.29 days, 95% CI −8.90 to −3.68). Non-invasive weaning also significantly reduced the total duration of ventilation, duration of invasive ventilation and duration of ventilation related to weaning (MD −0.57, 95% CI −1.08 to −0.07) and tracheostomy rate. Mortality, pneumonia, reintubation and ICU stay were significantly lower in trials enrolling COPD (vs mixed) populations.

Conclusion Non-invasive weaning significantly reduced mortality, pneumonia and the duration of ventilation related to weaning, particularly in patients with COPD. Beneficial effects are less clear (or more careful patient selection is required) in non-COPD patients.

PROSPERO registration number CRD42020201402.

  • critical care
  • COPD exacerbations
  • non invasive ventilation

Data availability statement

Data are available from KEAB. Data are available from Dr. Burns (0000-0002-9967-5424) .

https://doi.org/10.1136/thoraxjnl-2021-216993

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    Data availability statement

    Data are available from KEAB. Data are available from Dr. Burns (0000-0002-9967-5424) .

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    Footnotes

    • Twitter @karenburnsk

    • Correction notice This article has been corrected since it was published Online First. Some affiliations were listed incorrectly and a minor error was noted in Table 3.

    • Collaborators Not applicable.

    • Contributors KEAB conducted the literature searches, resolved discrepancies between citation reviewers, selected studies meeting inclusion criteria, assessed study quality, conducted risk of bias assessments, double checked data entry, prepared initial and subsequent drafts of the manuscript and integrated comments into revised versions of the manuscript. JS and ML screened abstracts, selected studies meeting inclusion criteria, abstracted data, assessed study quality, conducted risk of bias assessments and integrated comments into revised versions of the manuscript. YL, CL, ZL and LC assisted with screening articles for inclusion. YL, CL, XH, ZL, WW, LC and HZ translated articles, abstracted data, assessed study quality and conducted risk of bias assessments. NKJA provided methodologic guidance, aided with drafting the manuscript and integrated comments into revised versions of the manuscript. JOF provided methodologic guidance, assessed study quality and conducted risk of bias assessments, hand searched conference proceedings and integrated comments into revised versions of the manuscript. All authors revised and approved the final version of the manuscript.

    • Funding KEAB holds a career award from the Physician Services Incorporated Foundation.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.